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Central Florida Clinicians Handle Organ Donation After Cardiac Death
By Cindy Saver, RN, MS
Monday November 17, 2008
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For many years ethicists have debated, "When does life begin?" A lesser-known ethical question now being debated is "When does death begin?"

This question stems from the practice of organ donation after cardiac death (DCD, also referred to as non-heart-beating donation). It's a procedure that significantly boosts the number of organs — experts estimate as much as 48% — available for the nearly 98,000 people who desperately need them. For some clinicians, DCD is a boon; for others, it raises ethical questions that haven't been sufficiently answered.

Declaring Death

The Uniform Declaration of Death Act of 1980 gives two options for declaring death: (1) irreversible cessation of circulatory and respiratory function, referred to as cardiopulmonary death, or (2) irreversible cessation of all function of the brain, referred to as brain death. DCD puts the focus on the first option, cardiopulmonary death.

In a comatose patient with irreversible brain damage, after a specified time after asystole and cessation of circulation, death is declared and organ procurement begins immediately. Speed is essential to ensure the donor's organs are in the best possible condition for the recipient, so life support is removed near or in the OR.

Once the first decision has been made, the organ procurement organization coordinator and a family coordinator, from either the OPO or the hospital, talk with the family. Lynn Williams, RN, BSN, CCRN, CPTC, MBA, organ recovery coordinator with Translife, the OPO for Central Florida, says her OPO has at least 15 years' experience with DCD. "We don't bring up donation until the family has signed the papers for withdrawal," she says.

Regulations for organ donation vary slightly from state to state. As of January 2007, hospitals must have a policy that addresses DCD. Williams says the physician, who must be independent of the transplant team, usually declares death two minutes after the patient's heart rhythm is asystole. Death parameters are defined by the hospital, however, not the OPO. The transplant surgical team waits five more minutes before making the incision. During that waiting time, the patient is moved into the OR, where prepping and draping for surgery is completed.

The Controversy

Objections have arisen around several areas, including premortem care, time of death, and end-of-life care.

"Providing treatment in the interest of preserving organs is about the commitment the patient has to donate," says Lisa Day, RN, PhD, associate clinical professor at the University of California, San Francisco School of Nursing. Day participated in one of the working groups at the 2005 National Consensus Conference on Organ Donation after Cardiac Death. The working groups provided suggestions for DCD processes.

When DCD is planned, patients are given a large dose of heparin before withdrawal of life support to keep the blood from clotting in the organs. This has drawn criticism from those who say the large dose theoretically can cause death by worsening or causing intracerebral hemorrhage, thus violating the clinician's obligation to "do no harm." However, there is no clinical evidence that heparin, as opposed to the underlying pathology, causes patients to die.

Day says the ethical principle of double effect has been used by both sides to defend their position. Double effect states that in some cases, an action that has an unintended, harmful effect may be defensible in certain situations such as when the good effect outweighs the bad effect and when the bad effect is foreseen but unintended. "I don't believe medications are covered by the principle of double effect because they don't benefit the patient," says Day.

On the other hand, Barbara Daly, RN, PhD, FAAN, says, "The argument for giving meds is that it's our duty to promote good." Daly is a professor at Case Western Reserve University and director of the clinical ethics program for University Hospitals in Cleveland. "For this patient and family, their view of what's good is to be able to salvage some rescue in tragic situations."

Time of Death

"The hospital needs to have a procedure on how to declare death," says Day. In some hospitals that includes confirmatory tests such as intra-arterial monitoring or Doppler study.

The Society of Critical-Care Medicine recommends two minutes from asystole, but not more than five; the Institute of Medicine recommends five minutes. But current data are lacking, according to Joan McGregor, PhD, professor of philosophy and Lincoln professor of bioethics at Arizona Sate University in Tempe. "Only 109 patients were included in the commonly cited study by [Michael DeVita, MD]," she says. "The last one was in 1970. Medicine has changed a lot since then."

Another difficulty is autoresuscitation, or the spontaneous return of circulation, also known as the Lazarus syndrome. McGregor cites studies in which resuscitation occurred 10 to 15 minutes after the heart stopped and brain death did not occur.

"My concern is that there isn't sufficient information and dialogue and understanding about this procedure," says McGregor, who also believes there aren't enough experts outside of the transplant community included in the discussion. Like other critics, she cites the financial incentives for OPOs to obtain organs as one reason the transplant community should not be driving guideline development for DCD.

McGregor and other ethicists recommend the practice of mandated choice to help avoid some of the ethical issues related to organ donation. With mandated choice, all adults would be required to consider organ donation and document their decision. These wishes would be legally binding, as opposed to current policy, which allows a patient's wishes to be overruled by the family's wishes.

Educating Staff

Even with education, staff can have moral distress. These cases bring with them an emotional component, and staff often find them difficult.

Beginning Jan. 1, 2008, the Joint Commission stipulated that if the hospital and medical staff don't want to provide DCD and the OPO doesn't agree with the decision, the hospital must document its efforts to reach an agreement with the OPO, and the policy must address the justification for not providing DCD.

Cindy Saver, RN, MS, is a Nursing Spectrum contributing writer.

To comment, e-mail editorFL@nursingspectrum.com.

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